Simple drainage of intrathoracic suppurations

SIMPLE DRAINAGE

OF INTRATHORACIC

USE OF AN ENDOCUTANEOUS

SUPPURATIONS”

(ELOESSER) FLAP

LIEUT. COMDR. A. LINCOLN BROWN, M.C. U.S.N.R. SAN FRANCISCO, CALIFORNIA

T

HE value of any method for the treatment of intrathoracic suppurations which requires essentiaIly no after care is obvious at any time. This is particularly true both under the stress of civi1 or military medicine as during the present emergency. The cases upon which the present study is based come entireIy from civi1 practice. But this shouId in no way detract from the vaIue of the procedure in the miIitary service where, I believe, it wouId be unusuaIIy suitabIe. In 1935, EIoesserl described an operation for secondariIy infected tuberculous empyemas evoIved through desire to obviate the continuous use of a drainage tube. The operation consisted of forming a fingerIike flap of skin which was inserted through a thoracotomy wound into the pIeura. A tract was thus formed into the empyema cavity which, because of the presence of skin on one side and fascia1 structures on the other, remained open and required no attention other than dressings. This same flap produced a valve-like mechanism whereby material such as pus and air readily escaped from the empyema space but which acted to prevent the entrance of atmospheric air. Thereby a tendency to develop a negative pressure in the empyema space resuIted and expansion of the lung and obIiteration of the dead space was favored. This procedure appeaIed to us suffIcientIy to suggest its use in cases simiIar to those reported by EIoesser. The resuIts in these particuIar cases were suff&ientIy satisfactory to encourage its use in other intrathoracic fluid accumula-

tions. Fifty-four instances (Chart I) in which this procedure has been employed by us are analyzed so that the relative vaIue of this technic in various conditions may be evaluated. OPERATIVE TECHNIC The technic is simpIe. It is carried out uniformIy under IocaI anesthesia and usuaIIy consists of both fieId bIock and intercostar nerve bIock. The position of the patient on the tabIe is essentiaIIy that used for the introduction of an artificial pneumothorax. A site near the most dependent position of the cavity to be drained is seIected and when feasibIe the base of the flap is pIaced paraIIe1 with the line of the ribs. (Fig. I.) A ful1 thickness skin flap is fashioned. The total Iength of the flap is about 12 cm. and tapers somewhat so that the width of the base usuaIIy measures 6 cm. in width whiIe the width near the tip is about 4 cm. The ffap is so fashioned that subsequent movements of the shouIder girdIe wiI1 have the least tendency to pull thereon. At the same time the flap is fashioned any previousIy existing scar or sinus tract is excised. Thus an oId thoracotomy scar may be used as one border of the flap. (Fig. 2.) It is inadvisabre to incIude scar tissue in the flap for shouId this scar traverse the flap it materiaIIy interferes with circuration and nutrition. A section of rib about 3 or 4 cm. in Iength, with the underIying thickened pIeura, is removed in sufficient amount to aIIow the easy introduction of the tip of the ffap as we11 as a

* From the Dept. of Surgery, Division of Thoracic Surgery, University of California Medical School, and the San Francisco Department of PubIic He&h, San Francisco City and County Hospital and is being published with the further authority of Capt. E. E. Curtis, M.C., U.S.N. Ret., C.O. U.S. NavaI Dispensary, Treasure Island. The opinions expressed in this artick are entirely those of the author and no approva1 or disapproval by the MedicaI Department of the U.S. Navy is impIied. 169

170

American Journal of Surgery

Brown-Intrathoracic

Suppurations

NOVEMBER, 194,

CHART I

- -

-

I 1Bron-

Age jex

Name

(

Diagnosis

Type of Empyema

Organism FistuIa

ss

27

M

1Pulmonary TubercuIosis IMixed E mpyema, right

BM

28

n/r

I-B Spine (T-5, 6, 7,8,9, 1?ara-Vertebra1 Abscess 1Zmpyema 1‘soas Abscess

-

_-

IO

Mixed

Strep. TB

TB Empyema foIIowing Hibbs-AIbee fusion

TB

t

l-

AG

60

F

I,ung Embolus with empy ema right fhrombophIebitis, Ieg

Chronic empyema, right

Gram-positive

VL

34

M

IMixed TB Empyema,

Mixed empyema

TB B. Cob Strep. Viridans

AT

48

3mpyema foIIowing pneumonectomy

_

JP

34

Mixed cmpyema folIowing a spontaneom pneumothorax

TB Strep.

klixed TB empyema

I-B

vlixed empyema

Strep. M. Catarrhalis B. WeIchii

I3ronchiaI adenoma Ieft empyema following pneumonectomy

Zmpyema, left

Strep. hemolytic

I‘ost-pneumonic empyema, secondariIy infected with TB

flixed TB empyema (3 years duration)

TB ,Other?

I‘ulmonary TB 7rubercuIous empyema, right

vlixed TB empyema

TB Staph. (aureus) H. Strep. B. (H)

--

M

I3ronchogenic right

-

-

_-

-

STW

20

M

CR

47

M

TR

27

NC

25

-

M

-

-

ad-

_-

_-

f

-+

I-

+

--

I- -

Ieft

! ingio-sarcoma IZmpyema, left following pneumonectomy __

M -

-

IUmonary TB, far vanced pfiixed empyema (TB), I
F

37

Carcinoma,

IPuImonary TB, far advanced, biIatera1 rvlixed empyema, Ieft

M

-_

EW

right

-

cocci

I-

+

+

-,-I

-

--

-

-

Brown-Intrathoracic

NEW S~~res VOL. LX1 I, No. I

CHART

-

Course-Drainage

Gen&l

Suppurations

American Journal of surgerJ

I7 I

I (Continued) (Temperature,

Pulse,

Results

Cond&on)

of Flap Operation

Previous Drainage Results

EIoesser Flap

and

[mmediate IIllprovement

Improvement Within I Week

IITlprove ment #ithi n :WC!eEES

_-Tube-Jan. ‘33,

Nov.

1932, June ‘33;

BronNo lmUn_ provement changed

JeuraI kuIa Slosed

1: +

--

-~

___~

Chsed

I +

‘34

Not satisfactory

cho-

knJIerl

-~

+

6-25-34 (8 P.A.L.)

Mar.

Ultimate Imiprovement

3-1 I-36 (7 M.A.L.:

None

-I

-None

Tube drainage. ThoracopIasty (s-4 ribs) Rib resection (7-B-9 ribs) rg37-1941 Wound cIosed; did not help

--

Tube drainage not satisfactory

_. Tube-inadequate

None

2-I s-36

i

-

g-18-38

I

-

+

-. Tube drainage-3 Not satisfactory

None

year s z-18-36 3-17-37

-_

Tube drainage not sat. isfactory 4 months

I -3-38

-_

-.

NOIW

5-J 6-39

Rib resection 1933 Rib resection (same area) 1936 ~____ Rib resection 1g3owound closed in I yr Developed draining sinus-_3 yrs. Iatei (Empyema recurred

1o-3 ! -36

--

_~_

---

J-27-39

,

b -

(expired)

I72

Americsn

Journal

Brown-Intrathoracic

of Surgery

CHART Results

Suppurations

NOVEMBER,

194~

I (Continued)

of FIap Operation

Other Therapy Amount of Draina .Fand Dressing Requi red UItimateIy

_20-30 cc. daiIy I dressing daily

Secondary Operation Needed

Flap Held

Closure of Sinus

Later Course

-~

]No

+

No

Oleothorax I z-22-32 Phrenic Aralsion 5-27-33 ThoracopIasty I- I I ribs

I 1No

No

30-40 cc. daiIy

1No

Too soon

30 cc. daiIy (3 mo. Ia ter) I dressing daiIy

1No

Yes

I dressing daily

1No

No-7

5 cc. daiIy I dressing daily

No

No

tSecond operation

No

I-

?

‘33

-I-

200-300 cc. daiIy 2-3 dressings daily

--_

~None

INone

None

mo lnths

IN one

2

I!WI

3-17-37

draining

stage thoracopIasty

stage thoracopIasty I-IO ribs

2

__~ -

I dressing daily

IMazingo

tube

Yes (empj iema stiI1 press mt)

9-16-38

--

-I dressing daiIy

No

1VO

+

’Yes (empyema pres- Pneumonectomy ent) I I-29-37 iSatisfactory

drain-

age

-20-30 cc. pus daily 1-2 dressings daiIy

--1No

1VO

+

‘Satisfactory age

-_

___ No

1VO

+

-

J

-

Pneumonectomy 12-14-38

drain-

None

NEW SERIES VOL. LXII,

Age !jex

Name

MB

27

-FZ

Suppurations I (Continued)

CHART

Diagnosis

F

IB E mpyema

M

1Postpneumonic Ieft

American

Journal

I73

of Surgery

-

BronchopIeural FistuIa

Organism

Type of Empyema

1Pathological

TB E mpyema

report TB

-

-33

empyema.

63

M

6

OT

36

AL

25

JD

36

JE

41

PC

58

F

IPneumococcic cmpyema, right (chronic)

Pneumococcus Type III

(zhronic empyema

Strep. (Viridans) Staph. (aureus) 3. Proteus Diphtheroids

(zhronic TB empyema

TB

_(Chronic empyema,

right

-- M

1‘ulmonary TB, heaIed TB empyema

_- F

_- M

Strep. (Viridans) Staph. (albus)

-

_ CChronic pneumonococcic empyema, right

BJ

, 1Postpneumonic empyema

-

-WT

Brown-Intrathoracic

- - -

-

--__

No. z

1‘uImonary TB 1TB empyema

i7

IB empyema

TB

1Mixed TB empyema

TB staph. (albus)

(3ystic Disease of Iung

Izmpyema tube

jtaph. (aIbus), right kaph. (aureus), right

I‘ulmonary TB 1TB empyema

IB

‘uImonary TB ItvIixed TB empyema

nixed TB empyema

TB jtaph. (aIbus) 3. Strep. 3. Influenza

I‘ulmonary TB, far advanced, bilateral, cavity

Izmpyema, left (mixed TB)

TB staph. (aureus) Diphtheroid B.

1‘uImonary

TB

+ ___ _

_- M

_- - _M

folIowing

rB

+

hpyema

RT

28

SB

43

M

_~ ?

-

-

F

- - -

_!-

-_ +

i

174

American

Journal

of Surgery

Brown-Intrathoracic CHART

-

Suppurations I (Continued)

T Course-Drainage (Temperature, Genera1 Condition)

Previous Drainage ResuIts

am

NOYFMBEH, 19~3

-

I

Pulse,

Results

of Flap Operation

___

11

Eloesser FIap

Imme diate Improve. ment

ImImproveprovement ment Within Within 1 Week :I2 Week.

Ultimate Improvement

(

No Im Unprovehange ment ,C

I/ Bron-

I

imallcr

CIosed

pleura1 FistuIa CIosed

-I-

Rib resection and tube I drainage 5 yrs. (1932-1937) Inadequate drainage

Tube drainage-z Inadequate Rib resection-TInadequate Rib resection Inadequate

+

I

I-6-39

-I-

+

mo.

+

[O-3-39

I

None

I 3-39,. -__

I z-5-40.

/

1-9-4 1

t

j-15-40

+

---

-I-

Inade.

I3-I o-39

+

-__ _

l.

I.

-2 J$

I

1-16-38

I 2-I-39

I

2-27-39

+

+

None

None

-__ -

-__

--

___ +

I-

I-

+

+

___

.-

Tube Jan. 1936 to ApriI 1936 4 mos. Unsatisfactory

4 -13-36

None except centesis

7,-22-36

Thora-

-I-

_

+

-~ Tube drainage to I 2-16-39

-I-

-I-

+

-__

Tube drainage months Unsatisfactory

None

I.

None (Thoracentesis)

Rib resection. quate

j

--

--

--

Tube drainage 4 month s Rib resection-7 mo. Inadequate. May 1937 Rib resection--Iz-I-3s Inadequate

+

S-12-37

‘

None

+

-Tube 6-21-37 to 7-19-3; ’ 7‘-19-37 Drainage insuffIcient

-

_

I

- .-

-

-

New SERIESVOL.LXII. No. z

Brown-Intrathoracic CHART ResuIts

Suppurations

American

Journal

or surgery

I 75

I (Continued)

T

of FIap Operation

-

-

Other Therapy Amount of Drainage and Dressing Required UItimateIy

2-3 drops drainage

-I

Few drops of pus I dressing daily

I-

I dressing daily

Closure of Sinus

No

+

___

Secondary Operation Needed

Flap Held

I___

No

Satisfactory

No

Satisfactory

1st almost closed

Satisfactory

__-

No

Yes (revision 3-30-40)

on

_

-_

SIight amount of drain-

I

UO

age dressing daiIy

I dressing daily

Later Course

ThoracopIasty 8-13-38 Muscle plastic 8-13-38 MuscIe pIastic 8-25-39

--

No

,Satisfactory

No

Satisfactory

No

Not draining we11

I

-

I

Yes (increased size flap rr-rg41)

I dressing daily

5-7-42 rhoracoplasty --

Yes

-I dressing daily

I dressing as needed

No

+

+

NO

!No

+

No

No

Patient

1Robert’s operation g-r 3-37 and 9-24-37
No

Satisfactory

1VO

No

,Satisfactory -_

I dressing daily

I.- +

I dressing daiIy

+

-_

-I

thoracopIasty

9-27-37 zd stage 10-19-37 ;Phrenic crush 1-2 1-38

I

I- -

Drainage profuse 3-4 dressings daily

1st stage

Satisfactory

--

-

-expired

1None

Thoracoplasty 1st 1-4 ribs 5-17-37 2d-5-7 ribs 6-4-37 Sinus revision 7-30-37 Pinch graft 7-5-40

176

A mericsn Journal

-

Name

- -

Age

MM

21

JA

39

Mixed TB empyema, EpiIepsy

37

47

M

57

HO

47

MD

28

AT

43

EA

25

-_

-

-

3’

RC

36

-

-

t

._ IMixed TB empyema

IIMixed

TB empyema

(7hronic putrid empyema

TB Anaerobic

i -

Strep.

B. Strep. TB (Guinea pig)

I

Anaerobic Strep. Fusiform B.

I

Chronic empyema (pneun no- (zhronic empyema cocci) Atonic bIadder -____

Pneumococci Type I

Postabortion peIvic abscc :ss I‘utrid empyema and thrombophIebitis (acute) Postabortion septicemia Broncho-pneumonia Pulmonary emboIism Bacteria1 endocarditis

Staph. Strep. DipIococci

-

I +

-

__-

-

-I

.___

I

Diphtheria Broncho-pneumonia E mpyema Peritonitis

Izmpyema, strep., following pneumonia (chronic)

d. Strep.

BronchiaI adenoma Lobectomy Empyema necessitans Iowing operation

I 7mpyema foIIowing Iobectomy

NonhemoIyticstaph.

(albus)

Itmpyema following Iobectomy (partial)

NonhemoIyticstaph. TB (f-3-42)

(albus)

PuImonary TB, Ieft Lobectomy Empyema (staph.) & TB

_.

_.+

--

bvlixed TB empyema Chronic TB Empyema (mixed) 18 yes Lrs (draining sinus)

-

+

fc>I-

_.

F -

Gumma. Strep. Staph. (aureus) TB

_.

F -

t

_.

F

MK

not

_.

M

__

d. Strep. Guinea Pig +

_.

F

-

I’

Lung abscess Chronic empyema

M -

cho‘pIeural IFistuIa

Organism

._ zavity drainage, empyema

Mixed TB empyema Bacteremia (staph.)

M

1Mixed TB empyema

--

Pulmonary TB, far advanced Empyema, Ieft

AT

rig;ht

PuImonary TB, far advanced Diabetes MeIIitus (Lung abscess on entry)

--JO’M

Type of Empyema

-.

M

NOVEMBER, 19~3

I (Continued)

Diagnosis

M

--

-~

BZ

Suppurations

T

c

-

Brown-Intrathoracic CHART

F

--

-___

of Surgery

Staph. (aureus) hemoIytic

-

NEW SERIES VOL. LXII. No.

Brown-lntrathoracic

2

Suppurations

CHART

-

American

of

hrd

surgery I77

I (Continued)

(Sourse-Drainage General

(Temperature, Condition)

Pulse,

ResuIts

of Flap Operation

Previous Drainage Results

and

1 EIoesser

I.mme-

FIap

Tube 9-4-38 to 10-3 1-38

10-31-38

Open drainage of cavity 4-11-38 to

I I-29-39

diate ImI3rovement

Im/ Improveprovement ment Within Within I Week~zWeekz

UItimate Im;Irovement

qoImxovement

C

Wnhanged

;malIer

Closed

Bronchopleural Fistula CIosed

+

+

-

~

I I-29-39

Sinus revision 9- 15-39

___ +

-_

Tube 10-31-39 to 7-3140-9 months

7-3 r -40

.-__I_ None

-

I

None

--

9-25-40

i-

+

I

None

____--.--_Nov.-Dec. 1939. Inadequate Rib resection 6-24-40 Inadequate ___Iw

I o- I O-40

None

1 I -6-40

None

I I-16-40

i

-~

I 2-T-40

40 Inadequate

to

12-I 3-

12-I

I--None

_-

/I

I

3-40

None

-

___5-g-41

+

I-

-___

i

~-

I !

_--.I_c

I

-

3-4-4 1

+

2-1-41

-

-

I

-I-

_.~ ?

None

drainage

Wound open and drained 4-30-4 I

None

i-

I-

-_ Tube

-

-

+

None

178

American Journal of Surgery

Brown-Intrathoracic

Suppurations

CHART ResuIts

Amount of Drainage and Dressing Required I UItimateIy

___I dressing daily

+

Other Therapy Closure of Sinus

I

Later Course

-Abscess forme :d No in Aap woun Id drained twice (2 yrs. Iater) -_

I dressing daily

No

No

I dressing daiIy

No

No

No

IX0 1VO

-

I (Continued)

of Flap Operation

Secondary Operation Needed

Flap Held

NDYEMBER. 1943

Satisfactory for abscess

excer

,t

-_ Satisfactory

I

1FIap not as valve

Muscle Aap operation 8-10-38

workin

g None -_

-_

I dressing every 4 days

Satisfactory -

I dressing every 2 days

+

No

I dressing dairy

+

No

1VO

2-3 dressings daiIy

+

No

IVO

2-3 dressings daily

+

No

I\lO

10-15 cc. daiIy I dressing daily

+

No

20 cc. daily I dressing daily

+

+

-_

None -!_

Satisfactory

I None

Satisfactory

None

I

-_

Satisfactory

INone

r\TO

GraduaI improvement with Iess drainage and weight gain

1Lobectomy

No

P

Improving with cavity cIosing and Iess drainage

1lobectomy for possible tumor r 2-30-40 1PIastic repair i-9-42

No

IVO

Satisfactory

-

--

I dressing daiIy -

-

-.-

/INone

2-26-41

NEW

SERIES VOL. LXII,

No.

Brown-Intrathoracic

2

AmericanJournalor surgery

Suppurations

I

79

CHART I (Continued) I

j Name

iI

i Diagnosis

i Age ‘Sex 1

~ Type of Empyema

Bronchopleural Fistula

Organism

~ ’

I

I

-I

LP

M

50

Silicosis Empyema

!E mpyema

I

+

-i. ____________

-ITB

I&l

PuImonarv TB Mixed empyema

?&v;tvdra;ned

_~ RDS and 9 cases similar

Gram-neg. rods Anaerobic gram-neg. rods

F

‘9

PuImonary TB with tension cavity (+ 12)

-

i,B

_____ ~TB cavity drained

I

TB

+

I I .,---___

OT

GP

HS

57

1

25

1

hl

Mixed TB empyema

Occurred eariy in course of pneumothorax treatment ._~ I____

TB Mixed

Mixed TB empyema

Advanced bilateral pulmonary TB

TB Mixed

_______-----_

__-_-_-_-_

Chronic empyema

Chronic empyema --

JII

)

JPH

____ RW

hemolytic

~ +

staph.

TB (?)

‘9

M

Echinococcic

M

Interlobar empyema foIIowing pneumonia

Pneumococcic ema

M

Pulmonary TB, rt. ? TB extrapIeura1 empyema

FoIlowed extrapleura Mixed empyema

TB Staph. Strep. Diphtheroids

~ + I

Genera1 mixed empyema

Mixed empyema

Strep (Viridans) Proteus vulgaris Anaerobic diphtheroids

/

I 18

cyst

remova

PuImonary TB

of

empy-

/ 23

+

______ FoIlowed cyst

1..

HW

nonhamolytic

PuImonary TB TB empyema ____-__ --

-__

ss

_

F

I

-__-

1-p-p-TB empyema

~----

,

33

r7mo

RB

Anaerobic strep. ! Anaerobic

-

TB cavity drained

No growth

Pneumococcus

+

(type 1)

+

+

i I

._ TB

I

?

180

A ln
Brown -1ntrathoracic CHART :

I (Continued)

c oursePDrainage

General

Previous Drainage Results

and

I

Eloessel FIap

Immediate Improvement

None

None

(Temperature, Condition)

Pulse,

Results of FIap Operation

Closed Within Within I Week z Weeks

INone

NOVM~ER, IO.$J

Suppurations

____

_

provement

~~

Broncho1pIeural Frstula Closed

~_~ ~ ~~ ~-

I-13-39

l-

I-

+

None

II

None

?-27-40

-None

6-12-40

None

None

None

-~ None

12-19-40

None

10-18-41 IO-29-41

-+

+

+

+

-~

None

__CIosed thoracotomy 6-1-42

I -26-42 6-g-42

None except thoracentesis

None

:

+

6-4-42 6-26-42

+

+

Tube drainage prior to Jan. 1942

1-22-42

-

None

None

6-15-42

+

None

/

-

~.

L

-

NEW

SERIES VOL.LXII, No. a

Brown-Intrathoracic CHART ResuIts

Suppurations

American

Journal

of Surgery

18 I

I (Continued)

of FIap Operation

Other Therapy Amount

of Drainage

and D;e,zi;;tF\puiredI

Few drops daiIy ( 1o- 17-39) 1-13-41 increased drainage

I dressing daily

Secondary Operation Needed

1 ’ Flap fleId

’

+

NO

+

Yes g-10-38

+

No

CIosure of Sinus

Later Course

NO

Satisfactory

None

) No

Satisfactory

None

Satisfactory Negative sputum and drainage I mo. post-op.

Pneumothorax

Flap revision

1

CIosed on discharge

Yes

_

Yes

Too earIy

Too early

2-3 dressings daily

I +

No

Too earIy

’ Too early

I dressing daily

I +

No

No

2 dressings

I +

No

I dressing daily

left, Nov.

‘38 Extra-pleura1 2-S-39 1st stage thoracoplasty 10-27-39 2d stage 1-18-40

____~__ None

_____

,

~Satisfactory

None

NO

Satisfactory

None

No

No

1 Satisfactory

No

Too earIy

No

No

I dressing daily

Yes Revision 3-27-42 Open thoracotOmy 5-8-42

NO

I dressing daiIy

Yes 2nd stage Aap operation

Too early

daily

None

2 dressings daily

+

Thoracotomy for removal of echinococcic cyst I -5-42

I

i Satisfactory I

Satisfactory

None

DeveIoped puruIent meningitis 3 days after thoracotomy expired

’ Too early

Too earIy

i

182

A mericanJournal of Surgery

Brown-Intrathoracic

sufficient opening for drainage after the flap is in place. This opening is pIaced approximateIy under the center of the

FIG. I. Diagram iIIustrating usua1 site of Asp and approximate Iength of rib removed.

length of the flap, thus aIIowing adequate flap tissue to be turned in without tension. The pIeura1 space and Iung are now inspected, a11 secretions being aspirated and removed from the pIeura1 space. Before the flap is fastened the tip is denuded of excess fat tissue. The ffap is treated gentIy and very IittIe attention is paid to complete hemostasis as it is beIieved compIete hemostasis might jeopardize the viabiIity of the flap. A transfixation suture of No. I chromic catgut anchors the ffap to the parietal pIeura. (Fig. 3.) The wound edges are now approximated with nonabsorbabIe skin sutures as shown in Figure 4, care being taken not to cIose the wound too compIeteIy as this wouId tend to sea1 off the opening. Here it must be remembered that whiIe the flap is being fashioned the side of the chest and arm are in extension. The opening wiI1 appear Iarger in this position than when the arm is again pIaced at the patient’s side and the segment of thoracic waI1 is aIIowed to drop down. There is a tendency for the skin portion of the opening to contract during the earIy days and weeks. If one bears this in mind, an opening which at first seems too Iarge

Suppurations

NO\.EMBER. ,913

wiI1 be found to be the proper size in a short space of time. No tubes are inserted. It wiI1 now be found that in most in-

FIG. 2. Variation in direction and site of flap as might be indicated where an old thoracotomy scar may be used as one border of flap.

stances an opening has been produced which aIIows for egress of materia1 from the cavity but which on the other hand tends to have a vaIve-Iike action which prevents the entrance of air. Thus, there is a tendency to keep the cavity empty of contained secretions, but at the same time a negative pressure is usuaIIy developed which aids in the re-expansion of the underIying Iung. On rare occasions this negative pressure is so great that the patient is inconvenienced thereby. When this occurs he is taught to use a smaI1 catheter which can be inserted into the opening. This reIieves the vaIve action and aIIows the entrance of air, thereby bringing the intrapIeura1 pressure to neutral. A vaseIine gauze dressing is pIaced over the wound and ABD pads appIied. These are changed as frequentIy as the drainage necessitates. As the amount of drainage decreases a few Iayers of gauze are substituted for the pads. A simpIe jacket2 containing an oiIed siIk pocket to hoId the gauze directIy over the wound is often suppIied the patient. This jacket obviates the continua1 use of adhesive. The skin sutures must be Ieft unti1 they aImost

NEW

SERIES Var. LXII, No. z

Brown-Intrathoracic

sIough out as obviousIy the wound cannot fai1 to be infected by the drainage which flows over the raw surface; but, because of this free drainage, the Aimate healing of the wound readily takes place in about ten days without further interference. However, a few instances have presented themselves in which the opening has contracted sufficiently in subsequent weeks to warrant a simpIe enIargement thereof. Naturally this procedure does not of itself necessitate the patient’s remaining in bed.

Suppurations

American

Journal

or surgrry

I

83

surgica1 drainage to which the patient had been submitted (other than possibIe thoracentesis) (Table II.) Twenty-four

INDICATIONS

The fIap operation was performed on fifty-four patients. (TabIe I.) In twentynine instances this was the first type of TABLE I Flap Operation Performed for: Mixed Tuberculous Empyema., With bronchopleural IistuIa. . 8 Without bronchopIeura1 fistuIa.. 8 With probabIe bronchopIeura1 fistula.. I Tuberculous Empyema (drainage because of marked toxicity). . With bronchopleural tistula. 2 Direct TubercuIous Cavity Drainage.. I With fistuIa.. NontubercuIous Empyema Drainage.. With bronchia fistuIa.. 8 Cystic Disease of Lung. Silicosis plus Bronchopleural Fistula and Empy ema........................... Echinococcic Cyst.. TABLE it Flap Was Used as Primary Drainage Operation Mixed tuberculous empyema.. Direct drainage of tuberculous cavity.. Simple tubercuIous empyema. Chronic empyema (nontuberculous) Flap Used Secondarily (after other drainage unsatisfactory) Mixed tuberculous empyema.. Chronic empyema (nontubercuIous). Simple tuberculous empyema.. (I mixed tubercuIous empyema-previous drainage unknown)

17

6 12 16*

L I I 29

7 12

3 7 9 IZ 3

24

* (I Postpulmonary embolus 1 Postpneumonectomy for cancer 1 Postpneumonectomy for angio-sarcoma I Postpneumonectomy for bronchial adenoma I Postpneumonectomy for pulmonary tubercuIosis 8 Postpneumonococcic pneumonia (with IistuIa 2) I Postrupture Iung abscess I Postabortion thrombophlebitis and septicemia I Pleurisy accompanied by genera1 mixed empyema)

FIG. 3. Diagram illustrating fixation suture which holds the fIap in contact with the parietal pleura. It is to be noted that the subcutaneous tissue and fat have been gradualty tapered off the distal end of the 8ap.

after patients received the Aap operation other forms of surgica1 drainage (tubes, rib resections) had previousIy been found wanting over a period of months or even years. The history of one patient who received the flap operation is incomplete insofar as the record of any previous treatment is concerned. RESULTS

Of the fifty-four patients operated upon forty-six improved sooner or Iater by

184

A m&can

JournaIof Surgery

Brown-Intrathoracic

Suppurations

operation and eight were not benefited by it. Of those not benefited, one expired within twenty-four hours after operation.

Novmmm,

1')~)

in a very extensive empyema cavity. The other six were at Ieast not harmed by the operative procedure. The empyema cavity changed for the better, that is, became smaIIer in twentynine cases of which eIeven showed compIete obIiteration thereof. Of the cases having a bronchopIeura1 fistuIa at the time of operation this closed compIeteIy in ten cases. The flap has held in a11 but two instances. Secondary operations were ultimateIy performed to aid the status of the patient further in ten instances. CONCLUSIONS

FIG. 4. Reproduction representation of the method of cIosure and the appearance of the wound at the termination of the closure.

It must be admitted that he was practicahy moribund when drainage was instituted. Another which had had a ffap several months previousIy that had not functioned we11 expired about six days foIlowing a radical thoracotomy from a metastatic puruIent meningitis. This patient had a tremendous amount of necrotic material R&W&

TABLE III OF OPERATIVERESULTS(SEE CHARTI) IN

EACH

INDlVlDUAL

Immediate improvement.. Improvement in one week. Improvement in two weeks. Ultimate improvement. Noimprovement......................... Empyema cavity unchanged. Empyema cavity smalIer. Empyema cavity closed. Bronchopleural fist& cIosed. FIap held. _. Secondary

operation needed.

Sinus closed..

OBTAINED

The ffap operation appears to be of definite vaIue in the treatment of various types of intrathoracic coIIections of infIammatory material. This appears to be particuIarIy true when previous drainage operations have been of no avai1. AIthough, as can be seen from the reports, the primary use of the flap, especiaIIy in mixed tubercuIous empyema and for direct drainage of tubercuIous cavities, is often indicated and is a satisfactory measure. The advantage of any method for the drainage of intrathoracic suppurations, such as the endocutaneous ffap possesses, wouId be pecuIiarIy appIicabIe to such conditions under war time situations. This procedure has proved suitabIe in fifty-four patients whose ages varied from seventeen months to sixty-three years.

CASE 20

4 3

‘9

8

20

18

II Yes No Yes No Yes No

I2 5: z 10 44 3

Appreciation is extended to Dr. Sidney Shipman for permission to incIude nine cases of primary drainage of tubercuIous cavities and to Dr. Kazumi Kasuga for his efforts in the coIIection of statistica data incIuded herein. REFERENCES I. ELOESSER, LEO. An operation for tubercuIous empyema. Surg., Gynec. ti Obst., 60: rog6-1097, 1935. 2. BROWN, A. L. Universal dressing jacket for chronic chest sinuses. J. Tboracic Surg., IO: 713-7 I 4, 1941.